100M pounds a year spent on self-monitoring in diabetes that may increase anxiety and depression

The National Health Service (NHS) in the UK is spending £100 million a year to help people with non-insulin treated type 2 diabetes monitor their own blood sugar levels, but the process is more likely to make them depressed than provide any long-term health benefits, according to a series of articles published ahead of print on bmj.com today.

Globally one in twenty people have diabetes. The majority (85-95%) have type 2 diabetes, in which the body has either stopped making insulin or has difficulty making enough to convert blood sugar into the fuel our bodies need. Cases of type 2 diabetes are on the increase in the UK.

It has been generally acknowledged that self monitoring of blood glucose levels is beneficial for patients who have type 1 diabetes and those with type 2 diabetes who use insulin to treat their condition. However, the majority of people with type 2 diabetes do not use insulin, and it is for this group of people that there has been debate over the effectiveness of self monitoring. Yet, despite a lack of evidence, self monitoring has been widely promoted for this group in clinical practice.

Dr Maurice O'Kane and colleagues from the University of Ulster, report on a randomised controlled trial to assess whether self monitoring has an effect on blood glucose levels and the incidence of hypoglycaemia in people with newly diagnosed type 2 diabetes.

The researchers found no significant effect of self monitoring on blood sugar levels or cases of hypoglycaemia after a year. However, the patients in the self-monitoring group reported higher levels of depression and anxiety.

Evidence suggests that some patients find self monitoring "uncomfortable, intrusive and unpleasant". And the researchers suggest that the negative feelings reported in the study might be due to the enforced discipline of regular monitoring without any obvious benefit, rather than due to "feelings of powerlessness in the face of high blood glucose readings."

Self monitoring of blood glucose is the largest single management cost associated with implementing more intensive blood glucose control in the UK, with costs of providing test strips increasing from £85m to £118m between 2001 and 2003. Thus, it is important to establish if self monitoring represents a cost effective use of resources that could otherwise be used to finance other aspects of diabetes care.

In a separate study, Dr Judit Simon and colleagues from the University of Oxford, analysed the cost-effectiveness of helping patients with non-insulin treated type 2 diabetes self monitor their blood glucose levels in addition to standardised usual care, using data from the diabetes glycaemic education and monitoring (DiGEM) trial.

Their analysis confirms that self monitoring of blood glucose is significantly more expensive than the standardised usual care. They found that the additional healthcare costs of self monitoring were about £90 per patient each year. Furthermore, people who self monitored reported a lower quality of life probably owing to significant increases in their levels of anxiety and depression.

The authors say that self monitoring in addition to standardised usual care is unlikely to provide this group of patients with significant lifetime health benefits or be cost effective for the NHS. They conclude: "This study therefore provides no convincing evidence for routinely recommending self monitoring to patients with non-insulin treated type 2 diabetes."

In an accompanying editorial, Professor Martin Gulliford argues that the £100 million that is spent each year on self monitoring for this group of patients: "Represents a substantial opportunity cost in terms of alternative interventions that might have improved the health of people with diabetes...[such as] more effective disease control measures aimed not at blood glucose but also at blood pressure, cholesterol, smoking, body weight, and physical activity."

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